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Showing results for tags 'System safety'.
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Content Article
Blog - Is human error a crime? (2 November 2022)
Patient-Safety-Learning posted an article in Legal matters
Martin Anderson, author of the Human Factors 101 blog, looks at the case of US nurse RaDonda Vaught, who was found guilty of criminally negligent homicide and abuse of an impaired adult following a medication error that led to a patient death in 2017. He provides a timeline of the events that occurred in the run up to the criminal trial and highlights concerns that the case will set a precedent in bringing criminal charges against nurses when there is no intent to harm a patient. He then looks at the system factors that may have contributed to the medication error, asking a number of questions about the circumstances under which Vaught made the error. The blog goes on to outline the serious impact the case could have on healthcare professionals' willingness to report errors, take on complex cases and use innovative treatments—it may even put people off taking on a career in the healthcare sector in the first place. -
Content ArticleThe Covid-19 pandemic has, in many ways, been healthcare’s finest hour. Clinicians performed miracles as they battled to understand a new disease, learning as they went along the techniques and approaches that gave patients the best chance of survival. But, for all this quiet heroism, the crisis also turned a harsh spotlight on the deficiencies of health systems, writes Sarah Neville in this Financial Times article.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) third annual conference took place on 21 September 2022. Presentations and videos from the day are now available to view and download below. Although it tied in with the World Health Organization’s World Patient Safety Day theme of medication safety, our speakers also covered: how we can drive system level change practical sessions based on our HSIB investigation education courses maternity safety insights themed around inclusivity of care opportunities for sharing and learning from Norway’s healthcare safety investigation body, UKOM.
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Content ArticleIf you want to find out what the new Patient Safety Incident Response Framework is all about, and how it will support the NHS to learn and improve, this video provides a helpful introduction.
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Content ArticleIn this blog, The Patients Association's Chief Executive Rachel Power argues that the findings of the independent investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust demonstrate the repeated failure of maternity services in England to offer safe and compassionate care to families. She outlines the key findings of the report, including catastrophic failures in the organisation's culture, team working and professionalism, and failure to listen to patients. She highlights that the lack of honesty shown by the Trust to individuals and families harmed by the hospitals' failures is shocking, and compounded the suffering felt by each family.
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Content ArticleIn basic terms, a safety management system (SMS) is a formal arrangement for managing, assuring, and improving safety. An SMS is not a single document, it is a framework for managing all risks that arise from running a transport system. It defines roles and responsibilities, sets arrangements for safety mechanisms, involves workers in the process, and ensures continuous improvement. The Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS) introduced the requirement for and content of an SMS. The regulations require most railway operators to maintain an SMS, and hold a safety certificate or authorisation indicating that the SMS has been accepted by the Office of Rail and Road.
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Content Article
Skybrary: Safety Management System in aviation
Patient Safety Learning posted an article in Organisational
The objective of a Safety Management System is to provide a structured management approach to control safety risks in operations. Effective safety management must take into account the organisation’s specific structures and processes related to safety of operations. -
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On his last day in office at the Healthcare Safety Investigation Branch (HSIB), outgoing Chief Investigator Keith Conradi wrote to the Secretary of State for Health and Social Care reflecting on his time at HSIB. He outlined concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB and the need to introduce a safety management system approach at all levels of healthcare. Patient Safety Learning also shared our thoughts on the issues raised in this letter and we were keen to explore these issues, and Keith’s experience as HSIB’s first Chief Investigator, in greater depth. Here, Patient Safety Learning provides an overview of the recent interview we had with Keith Conradi on this subject. The full transcript of the interview is available to download in the attachment at the end. -
Content ArticleThis NHS England podcast examines how the application of system-based approaches to learning from patient safety incidents will be vital to the success of the Patient Safety Incident Response Framework (PSIRF). Guests Darren Thorne from the consultancy Facere Melius, Jane Carthey, a Human Factors and Patient Safety Consultant and Laura Pickup from the Healthcare Safety Investigation Branch (HSIB) discuss NHS England's learning response toolkit.
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Content ArticleA themed review may be useful in understanding common links, themes or issues within a cluster of investigations or incidents. It will seek to understand key barriers or facilitators to safety using reference cases (e.g. individual datix incidents or previous investigations).
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Content ArticleThe Australian Institute of Health Innovation conducts world-class research to catalyse health service and systems improvements in Australia and internationally. Its research generates highly practical evidence-based recommendations and information that health services can implement or use now. The Health Innovation Series supports clinicians, hospitals, policy makers and developers to apply this evidence to enhance the health system and services. The Health Innovation Series communicates research evidence in an easy-to-read, short format with clear recommendations, covering a wide range of topics.
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Content ArticleThe National Medication Safety Symposium was held in Sydney, Australia, in support of World Patient Safety Day. The presentations from the 2-day conference can be viewed on YouTube from link below.
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Content ArticleThis document outlines how Health Education England (HEE) hopes to expand the role of simulation and immersive learning technologies in the education and training of the NHS workforce. Simulation is defined as ‘a technique to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully safe, instructive and interactive fashion’. This document considers how existing techniques and technologies can benefit wider policy and strategy goals in health and care, outlining HEE's intention to: promote and strengthen the dialogue between different system and stakeholder organisations, networks, and communities to enable and evaluate opportunities for sharing intelligence and innovation provide a platform for collaboration on common themes of work generate evidence of impact that will help support the transformation in health and care that is required for the future needs of patients and society.
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Content Article
Patient Safety Commissioner for Scotland Bill (6 October 2022)
Mark Hughes posted an article in Scotland
The Scottish Government has published a new Bill to establish a Patient Safety Commissioner for Scotland. This article provides an overview of the remit, accountability, powers, and responsibilities of the new Commissioner that are proposed in this Bill. -
Content Article
What is safety management system? (31 August 2022)
Patient Safety Learning posted an article in Organisational
Safety Management System (SMS) is a collection of structured, company-wide processes that provide effective risk-based decision-making for daily business functions. A SMS helps organisations offer products or services at the highest level of safety and maintain safe operations. This article explains more. -
Content Article
HSE: Health and safety management systems
Patient Safety Learning posted an article in Organisational
A formal management system or framework can help you manage health and safety. The Health and Safety Executive (HEE) highlights standards, documentation and useful resources. -
Content ArticlePreventable harm, from the systems of care intended to improve health, continues to occur at an unacceptable rate in the United States. Healthcare systems have an opportunity to learn and improve from each episode of preventable harm. Accordingly, every preventable patient death or injury must energise our efforts to prevent future patient harm. The Anesthesia Patient Safety Foundation (APSF) believes that criminal prosecution of healthcare providers will make the work of preventing harm more difficult since it continues to shift the focus away from system improvements. They have released a position and policy statement outlining the rationale for opposing criminal prosecution and, equally important, recommends that all healthcare systems and organisations aggressively act, now, to improve their culture, processes, and training to reduce errors of all kinds and, specifically in light of recent events, medication errors. Some specific actions are recommended as examples of what can be done. Individual healthcare professionals should be mindful of their role in preventing errors and reporting errors that occur as well as taking action to encourage and enable their organization to improve the flaws in the systems in which they work that lead to harm to patients.
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Content ArticleFor two decades, Swiss Cheese theory has been an influential metaphor in safety science and accident prevention. It has made barrier theory and the impact of safety culture on operational safety more understandable to the upper echelons of high-risk organisations in many industrial sectors. Yet sometimes the Swiss Cheese model is used to focus on the operational ‘sharp end’ and unsafe acts, like a magnifying glass that acknowledges organizational influence, but still targets the human operator. It is time to ‘turn this lens around and allow organisations to focus on the upstream factors and decision-making that can engender these unsafe acts in the first place. This paper reports on an approach to do this, under development in the Maritime sector, called Reverse Swiss Cheese.
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Content ArticleThis article published by the Royal College of Nursing (RCN) aims to explain how health services in the UK protect patient safety during industrial action by nurses. It describes the principle of derogations, an exemption from taking part in strike action given to particular RCN members or services. Any RCN industrial action must follow the life-preserving care model. This exempts: emergency intervention for the preservation of life or the prevention of permanent disability. care required for therapeutic services without which life would be jeopardised or permanent disability would occur. urgent diagnostic procedures and assessment required to obtain information on potentially life-threatening conditions or conditions that could potentially lead to permanent disability. The article goes on to explain the process by which derogations are granted, and talks about balancing the need to maximise the impact of the strike while keeping patients safe.
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Content ArticleThis chapter from the book 'Managing future challenges for safety' starts with the premise that the future of work is unpredictable. This has been illustrated by the COVID-19 pandemic, and further profound changes in contexts of work will bring significant and volatile changes to future work, as well as health, safety, security, and productivity. Micronarrative testimony from healthcare practitioners whose work has been affected dramatically by the emergence of the pandemic is used in this chapter to derive learning from experience of this major change. The narratives concern the nature of responding to a rapidly changing world, work-as-imagined and work-as-done, human-centred design and systems thinking and practice, and leadership and social capital. Seven learning points were drawn from clinicians’ reflections that may be more widely relevant to the future of work.
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Content ArticleIt won’t come as a surprise but more than in 9 in 10 of almost 200 NHS leaders that responded to the latest NHS Confederation survey said that risk to patient safety is going to increase as we approach winter. Almost all of them identified the biggest risks being demand for urgent and emergency care and ambulance waits. And most expect to have to make difficult decisions and compromises around safe staffing ratios and delayed transfers of care. As the health and care sector braces for a challenging winter, three key steps could support systems to manage risk and minimise harm, writes Matthew Taylor, chief executive at NHS Confederation: The need for a robust and honest assessment of harm. The role of systems in minimising harm. The role of the centre in providing a helping hand.
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Content ArticleLearning from mistakes generally is considered the upside to failure. But in healthcare, where staff members regularly face stressors and systemic issues that impede a strong culture of safety, creating that standard can be difficult. To understand why medical mistakes and care complications occur repeatedly Becker's spoke with Patricia McGaffigan, vice president of safety programmes for the Institute for Healthcare Improvement. Ms. McGaffigan outlined three factors that contribute to repeat medical errors, care complications or lost progress on quality improvement initiatives: A "whack-a-mole" approach to safety. Lack of focus on systemwide changes. Unhealthy or unsafe work environments.
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Content ArticleThis article by Penelope Hawe from the Menzies Center for Health Policy at the University of Sydney, looks at complexity and how it increases the unpredictability of interventions in systems. She argues that new metaphors and terminology are needed to capture the recognition that knowledge generation comes from the hands of practitioners as much as it comes from intervention researchers.
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Content ArticleThe PDSA - a four-step model for improvement - has been used to support improvement in healthcare for many years now. The Institute for Healthcare Improvement (IHI) describe it as ‘shorthand for testing a change — by planning it, trying it, observing the results, and acting on what you learn. It is the scientific method, used for action-oriented learning in real-life situations. It is common to all improvement methodologies.’ In this blog, LifeQI takes a look at why the ‘Plan-Do-Study-Act’ or PDSA cycle is so widely used within healthcare organisations. It delves into the benefits – and any disadvantages – of using PDSAs in healthcare and how you can use them to drive quality improvement.
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Content ArticleReliable patient identification is essential for safe care, but system factors such as working conditions, technology, organisational barriers and inadequate communications protocols can interfere with identification. This study in the Journal of Patient Safety aimed to explore systems factors contributing to patient identification errors during intrahospital transfers. The authors observed 60 patient transfer handovers and found that patient identification was not conducted correctly in any of them (according to the hospital policy at every step of the process). The principal system factor responsible was organisational failure, followed by technology and team culture issues. The authors highlight a disconnect between the policy and the reality of the workplace, which left staff and patients in the study vulnerable to the consequences of misidentification.
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